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In the Clinic
Concussion
Prevention page ITC2-2
Diagnosis page ITC2-4
Treatment page ITC2-9
Prognosis page ITC2-13
Tool Kit page ITC2-14
Patient Information page ITC2-15
CME Questions page ITC2-16
Physician Writers
Christina L. Master, MD
Laura Balcer, MD
Michael Collins, PhD
Section Editors
Deborah Cotton, MD, MPH
Darren Taichman, MD, PhD
Sankey Williams, MD
The content of In the Clinic is drawn from the clinical information and education
resources of the American College of Physicians (ACP), including ACP Smart
Medicine and MKSAP (Medical Knowledge and Self-Assessment Program). Annals
of Internal Medicine editors develop In the Clinic from these primary sources in
collaboration with the ACPs Medical Education and Publishing divisions and with
the assistance of science writers and physician writers. Editorial consultants from
ACP Smart Medicine and MKSAP provide expert review of the content. Readers
who are interested in these primary resources for more detail can consult
http://smartmedicine.acponline.org, http://www.acponline.org/products_services/
mksap/15/?pr31, and other resources referenced in each issue of In the Clinic.
CME Objective: To review current evidence for prevention, diagnosis, treatment,
and prognosis of concussion.
The information contained herein should never be used as a substitute for clinical
judgment.
2014 American College of Physicians
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Who is at risk for concussion?
Reports indicate that youths aged
1019 years are at the highest risk
among the general population (3).
In addition to sports, concussions
commonly occur with such events
as falls and motor vehicle accidents
(1). In general, males have a higher
rate of concussions than females,
but there is evidence that females
may have a higher risk for concus-
sion in sports with similar rules (for
example, soccer or basketball) (4).
A comprehensive descriptive study pub-
lished in 2012 described the epidemiolo-
gy of concussion in high school athletes
by examining data from the Reporting
Information Online (RIO) system of the
National High School Sports-Related In-
jury Surveillance System. Researchers
found that concussions represented
13.2% of all reported injuries, which is an
increase from the previously reported
5.5%8.9% in studies published from
1999 through 2007. The concussion rate
was higher in competition (6.4 per 10
000 athlete exposures [AEs]) than in
practice (1.1 per 10 000 AEs), with ath-
lete exposure defined as a practice or
game. The highest rates of concussion
occurred in football (6.4 per 10 000 AEs),
boys ice hockey (5.6 per 10 000 AEs),
boys lacrosse (4.0 per 10 000 AEs), girls
soccer (3.4 per 10 000 AEs), girls lacrosse
(3.5 per 10 000 AEs), and girls basketball
(2.1 per 10 000 AEs). In basketball and
soccer, 2 sports with similar playing
rules, the rate of concussions was higher
among girls than boys (relative risks, 1.3
[95% CI, 1.01.8] and 1.8 [CI, 1.42.3], re-
spectively). Overall, symptoms resolved
within 3 days in more than 40% of ath-
letes, and most (55.3%) returned to play
within 3 weeks, with 22.8% returning to
play within 1 week (4).
Concern is growing that younger
children may be at higher risk for
prolonged symptoms from concus-
sion, perhaps due in part to the
immature nature of their develop-
ing nervous systems (5, 6). Other
comorbid conditions that have
been shown to be risk factors for
prolonged recovery from concus-
sion include preexisting anxiety or
depression (7), a history of multi-
ple concussions (8), preexisting
migraine (9), and diagnosed learn-
ing disability (10, 11).
Are certain types of head trauma
more likely to cause concussion?
Any type of head trauma can cause
concussion; in fact, direct trauma
to the head is not necessary for
concussion to occur. Any event in
which forces cause the brain to
move within the skull may result
in concussion; indirect forces
transmitted to the head from an
impact to the body (for example,
whiplash) may be sufficient to
cause concussion.
How can concussions be
prevented?
Upon sustaining an impulsive
force to the head, the brain accel-
erates and decelerates within the
fixed space of the human skull,
leading to an injury to the brain
that results in the clinical syn-
drome of concussion. Primary
prevention of concussion is
achieved by reducing or minimiz-
ing risk for exposure to such
forces. These measures often pre-
vent potentially catastrophic brain
injury but may still result in con-
cussion or mild traumatic brain
injury. Such an example would be
wearing seat belts while in a mo-
tor vehicle, which can prevent
2014 American College of Physicians ITC2-2 In the Clinic Annals of Internal Medicine 4 February 2014
1. Langlois JA, Rutland-
Brown W, Wald MM.
The epidemiology
and impact of trau-
matic brain injury: a
brief overview.
J Head Trauma Reha-
bil. 2006;21:375-8.
[PMID: 16983222]
2. Moreno MA. Advice
for patients. Children
and organized sports.
Arch Pediatr Adolesc
Med. 2011;165:376.
[PMID: 21464388]
3. Centers for Disease
Control and Preven-
tion. Nonfatal trau-
matic brain injuries
related to sports and
recreation activities
among persons aged
=19 years-United
States, 2001-2009.
MMWR Morb Mortal
Wkly Rep.
2011;60:1337-42.
[PMID: 21976115]
4. Marar M, McIlvain
NM, Fields SK, Com-
stock RD. Epidemiolo-
gy of concussions
among United States
high school athletes
in 20 sports. Am J
Sports Med.
2012;40:747-55.
[PMID: 22287642]
5. Shrey DW, Griesbach
GS, Giza CC. The
pathophysiology of
concussions in youth.
Phys Med Rehabil
Clin N Am. 2011;
22:577-602, vii.
[PMID: 22050937]
6. Field M, Collins MW,
Lovell MR, Maroon J.
Does age play a role
in recovery from
sports-related con-
cussion? A compari-
son of high school
and collegiate ath-
letes. J Pediatr.
2003;142:546-53.
[PMID: 12756388]
7. Ponsford J, Cameron
P, Fitzgerald M, Grant
M, Mikocka-Walus A,
Schnberger M. Pre-
dictors of postcon-
cussive symptoms
3 months after mild
traumatic brain in-
jury. Neuropsycholo-
gy. 2012;26:304-13.
[PMID: 22468823]
A
s many as 3.8 million mild traumatic brain injuries occur annually in
the United States. Many of them are sports- and recreation-related,
and more than 800 000 Americans seek outpatient care for this
injury each year (1). With more than 40 million children participating in
organized sports annually (2), children and adolescents represent a large
proportion of injured persons.
Prevention
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2014 American College of Physicians ITC2-3 In the Clinic Annals of Internal Medicine 4 February 2014
ejection of drivers and passengers
but may still result in the trans-
mission of angular accelerational
forces to the brain that can result
in concussion. In sports, helmets
have also reduced the incidence of
catastrophic brain injury, but date
are insufficient to support any
claim that helmets prevent con-
cussion. Protective equipment,
such as helmets and mouth-
guards, should be well-fitted and
properly used according to the
rules of the sport and may reduce
rotational forces associated with
concussion but has not been
shown to prevent concussion (12).
In contrast, rule changes in
sports, such as increasing the
body-checking age in youth ice
hockey, have been shown to re-
duce risk by decreasing exposure
to concussive forces (13, 14).
Secondary prevention is a key
principle in the management of
acute concussion. The patient
must be completely recovered
from an initial concussion before
reexposure to risk for a second
concussive injury. Clinical and
pathophysiologic evidence indi-
cates that a second concussion
soon after the initial one may
prolong signs and symptoms and
result in a protracted recovery
(15). There is considerable debate
about whether catastrophic death
or disability occurs in the setting
of a presumed second head injury
after a recent initial head injury.
In case reports, this seems to oc-
cur primarily in adolescent males
(16).
A prospective cohort study of 280 con-
secutive patients aged 11 to 22 years in
2013 found that children with a history
of concussioneither recent (within
1 year [P < 0.007]) or multiple concus-
sions (P < 0.03)were at increased risk
for prolonged symptoms after a subse-
quent concussion compared with those
with no history of concussion. Children
with concussion within 1 year had near-
ly 3 times the median duration of symp-
toms compared with those with no
previous concussion or those who had
concussion more than 1 year earlier. Pa-
tients with 2 or more previous concus-
sions had more than double the median
symptom duration compared with pa-
tients with no more than 1 previous con-
cussion. In contrast, patients with a
single concussion more than 1 year be-
fore the current concussion had no sta-
tistical difference in the duration of
concussion symptoms compared with
those with no previous concussion. A to-
tal of 63.8% of the 280 patients had
sports-related concussion, and the most
common symptoms on presentation
were headache (85.1%), fatigue (64.7%),
and dizziness (63.0%) (15).
This is particularly important
when concussion is sustained in
an athletic setting in the context
of a sport season, where premature
return to the sport may dramati-
cally increase the athletes short-
term risk for further head trauma.
During management of an acute
concussion, eliminating unneces-
sary risk for repeated head trauma
during the acute recovery period is
essential. Athletes should be com-
pletely recovered before returning
to any sport that would place
them at risk for a repeated head
injury.
8. Schulz MR, Marshall
SW, Mueller FO, Yang
J, Weaver NL, Kals-
beek WD, et al. Inci-
dence and risk fac-
tors for concussion in
high school athletes,
North Carolina, 1996-
1999. Am J Epidemi-
ol. 2004;160:937-44.
[PMID: 15522850]
9. Register-Mihalik J,
Guskiewicz KM, Mann
JD, Shields EW. The
effects of headache
on clinical measures
of neurocognitive
function. Clin J Sport
Med. 2007;17:282-8.
[PMID: 17620782]
10. Kontos AP, Elbin RJ,
Schatz P, Covassin T,
Henry L, Pardini J, et
al. A revised factor
structure for the
post-concussion
symptom scale:
baseline and post-
concussion factors.
Am J Sports Med.
2012;40:2375-84.
[PMID: 22904209]
11. Zemek RL, Farion KJ,
Sampson M, McGah-
ern C. Prognostica-
tors of persistent
symptoms following
pediatric concus-
sion: a systematic re-
view. JAMA Pediatr.
2013;167:259-65.
[PMID: 23303474]
12. Navarro RR. Protec-
tive equipment and
the prevention of
concussion - what is
the evidence? Curr
Sports Med Rep.
2011;10:27-31.
[PMID: 21228647]
13. Emery CA, Hagel B,
Decloe M, Carly M.
Risk factors for injury
and severe injury in
youth ice hockey: a
systematic review of
the literature. Inj
Prev. 2010;16:113-8.
[PMID: 20363818]
14. Cusimano MD,
Taback NA, McFaull
SR, Hodgins R,
Bekele TM, Elfeki N;
Canadian Research
Team in Traumatic
Brain Injury and Vio-
lence. Effect of
bodychecking on
rate of injuries
among minor hock-
ey players. Open
Med. 2011;5:e57-64.
[PMID: 22046222]
15. Eisenberg MA, An-
drea J, Meehan W,
Mannix R. Time in-
terval between con-
cussions and symp-
tom duration.
Pediatrics.
2013;132:8-17.
[PMID: 23753087]
Prevention... Primary concussion prevention can only occur by reducing exposure
to concussive forces and injury, which is primarily achieved by rule changes in
sports or enactment of laws for safety reasons. Once concussion has occurred,
secondary prevention with appropriate and knowledgeable clinical management is
essential, including restricting athletes from participating in activities that would
place them at increased risk for a second head injury before complete recovery
from the first injury.
CLINICAL BOTTOM LINE
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16. McCrory P, Davis G,
Makdissi M. Second
impact syndrome or
cerebral swelling af-
ter sporting head in-
jury. Curr Sports
Med Rep.
2012;11:21-3.
[PMID: 22236821]
17. Pardini D, Stump J,
Lovell M, Collins M,
Moritz K, Fu F. The
post-concussion
symptom scale
(PCSS): a factor
analysis. Br J Sports
Med. 2004;38:661-2.
18. Langer PR, Fadale
PD, Palumbo MA.
Catastrophic neck
injuries in the colli-
sion sport athlete.
Sports Med Arthrosc.
2008;16:7-15.
[PMID: 18277257]
19. Papa L, Stiell IG,
Clement CM,
Pawlowicz A, Wol-
fram A, Braga C, et
al. Performance of
the Canadian CT
Head Rule and the
New Orleans Criteria
for predicting any
traumatic intracra-
nial injury on com-
puted tomography
in a United States
Level I trauma cen-
ter. Acad Emerg
Med. 2012;19:2-10.
[PMID: 22251188]
2014 American College of Physicians ITC2-4 In the Clinic Annals of Internal Medicine 4 February 2014
What acute symptoms
immediately after head injury
should prompt consideration of
concussion?
Indications that concussion has oc-
curred include headache, dizziness,
balance or visual problems, nausea,
vomiting, or feeling slow after a
head injury (Table 1). Patients who
initially have minimal or no symp-
toms immediately after a head in-
jury should be observed carefully
over subsequent hours and days for
development of any signs or symp-
toms of concussion (17). Many ath-
letes may not present with acute
symptoms within the first 24 hours
of injury.
Occasionally, patients will present
with this constellation of symptoms
without a clear history of head in-
jury. In athletes in contact and col-
lision sports, such as football and
ice hockey, concussion should still
be considered in light of the many
impacts that such athletes sustain
in the routine course of their sport.
Clinicians should maintain a suffi-
ciently high index of suspicion in
the context of a recent head injury
so that they do not miss the diag-
nosis of concussion in sport. In
contrast, the symptom complex is
sufficiently nonspecific that, in the
absence of a clear history of trauma
to the head or an impulsive force
transmitted to the brain, causes
other than concussion may need to
be considered (see the Box: Con-
cussion Symptoms After Injury).
What evaluation should be
performed immediately after
head injury to assess whether
concussion or other serious injury
has occurred?
On the field of play, it is essential to
first assess for any associated cervical
or intracranial injury. If the patient
is conscious, they may be verbally
engaged while immobilized for the
cervical assessment. Signs of cervical
tenderness or limitation of cervical
range of motion during physical ex-
amination warrant immediate im-
mobilization and removal on a spine
board for transport to an emergency
department (18).
Concussion is a clinical diagnosis
that is made once more significant
injuries have been excluded. The
clinical concussion evaluation in-
volves various domains of brain
function, specifically neurocognitive,
balance, and eye tracking. A specifi-
cally targeted assessment of each of
these systems is important in making
the clinical diagnosis of concussion.
In a patient with brief or prolonged
(>5 minutes) loss of consciousness
or with traumatic convulsive activity,
referral for further assessment in the
emergency department should be
considered (19). Any patient with
deteriorating mental status or who
develops focal neurologic signs
should be referred to the emergency
setting for evaluation for possible
Diagnosis
Concussion Symptoms After Injury
Early (minutes and hours later)
Headache
Dizziness or vertigo
Lack of awareness of surroundings
Nausea or vomiting
Balance problems
Visual disturbance
Mental confusion
Amnesia (retrograde or anterograde)
Perseveration
Late (days to weeks later)
Persistent low-grade headache or head
pressure
Lightheadedness
Poor attention and concentration
Memory dysfunction
Easy fatigability
Irritability and low tolerance of
frustration
Intolerance of loud noises, sometimes
with ringing in the ears
Anxiety and/or depressed mood
Numbness or tingling
Sleep disturbance
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20. Kuppermann N,
Holmes JF, Dayan PS,
Hoyle JD Jr, Atabaki
SM, Holubkov R, et
al; Pediatric Emer-
gency Care Applied
Research Network
(PECARN). Identifica-
tion of children at
very low risk of clini-
cally-important brain
injuries after head
trauma: a prospec-
tive cohort study.
Lancet. 2009;
374:1160-70.
[PMID: 19758692]
21. Virji-Babul N, Borich
MR, Makan N, Moore
T, Frew K, Emery CA,
et al. Diffusion ten-
sor imaging of
sports-related con-
cussion in adoles-
cents. Pediatr
Neurol. 2013;48:24-9.
[PMID: 23290016]
2014 American College of Physicians ITC2-5 In the Clinic Annals of Internal Medicine 4 February 2014
intracranial hemorrhage. Once in
the emergency setting, a detailed
history and physical examination, as
well as continuous observation, are
essential. Concern for intracranial
hemorrhage based on clinical signs
and symptoms or deterioration may
prompt imaging with head comput-
ed tomography (CT).
What imaging tests should be
used to evaluate for possible
concussion? Do all patients
require them?
Routine imaging with CT after
head injury is not universally indi-
cated and should be considered on
an individual basis (19). Head CT
is the imaging method of choice in
the acute emergency setting if there
is concern for intracranial hemor-
rhage based on clinical signs and
symptoms or deterioration of neu-
rologic status. Evidence-based clin-
ical prediction rules have been
developed in an attempt to minimize
unnecessary exposure to radiation in
the use of head CT in the setting of
pediatric head trauma (20).
A prospective cohort study of children
younger than 18 years with head trauma
in a pediatric emergency department re-
search network evaluated 42 412 children,
25 283 of whom were aged 2 years or old-
er, to validate a prediction rule that would
identify a population for whom head CT
scan could be avoided. For children aged
2 years or older, the clinical prediction rule
with normal mental status, no scalp
hematoma except frontal, no loss of con-
sciousness, no vomiting, nonsevere injury
mechanism, no signs of basilar skull frac-
ture, and no severe headache had a nega-
tive predictive value of 99.95% (CI,
99.81%99.99%) and sensitivity of 96.8%
(CI, 89.0%99.6%). The clinical prediction
rule did not miss any clinically important
conditions requiring neurosurgical inter-
vention and is highly accurate at identify-
ing which children with head trauma do
not require head CT scan (20).
Historically, concussion has been a
radiologic diagnosis of exclusion:
signs and symptoms consistent with
concussion with normal imaging
studies. Currently, no clinical imag-
ing method can be used to make the
diagnosis of concussion once a more
severe traumatic brain injury has
been excluded. Many methods are
under investigation for use in con-
cussion, including diffusion tensor
imaging (21), functional magnetic
resonance imaging, and magnetic
resonance spectroscopy. However,
these are currently primarily limited
to the research setting.
When head injury occurs during
sport, how should the safety of
returning to play be evaluated,
and by whom?
An athlete should never return to
play on the same day a head injury
Table 1. Physical Examination Deficits in Concussion
Physical Examination Findings
Smooth pursuits: Examiners finger moves Unable to visually track; jerky jumpy movements;
horizontally, progressively increasing speed provokes symptoms, such as headache, dizziness,
eye fatigue, and physical signs, such as tearing/
watering of eyes
Saccades: Examiners fingers held at shoulder- Unable to perform or can perform only a few
width and forehead and chin distance to test repetitions before symptoms or signs provoked
horizontally and vertically as above
Gaze stability: Patient fixes gaze on examiners Unable to perform or can perform only a few
thumb while nodding (vertical) and then repetitions before symptoms or signs provoked
shaking (horizontal) head as above
Convergence insufficiency: Patient takes a pen Letters become blurry or double at >6 cm from
with letters and holds at arms length and the tip of nose
brings towards their nose until letters become
blurry/double
Balance: Tandem heeltoe gait forward and Unable to perform rapidly with arms at the side;
backward with eyes opened and closed raises arms, widens gait, or has extreme truncal
swaying
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22. McCrory P,
Meeuwisse WH,
Aubry M, Cantu B,
Dvork J, Echemen-
dia RJ, et al. Consen-
sus statement on
concussion in sport:
the 4th International
Conference on Con-
cussion in Sport
held in Zurich, No-
vember 2012. Br J
Sports Med.
2013;47:250-8.
[PMID: 23479479]
23. Harmon KG, Drezner
JA, Gammons M,
Guskiewicz KM, Hal-
stead M, Herring SA,
et al. American Med-
ical Society for
Sports Medicine po-
sition statement:
concussion in sport.
Br J Sports Med.
2013;47:15-26.
[PMID: 23243113]
24. Giza CC, Kutcher JS,
Ashwal S, Barth J,
Getchius TS, Gioia
GA, et al. Summary
of evidence-based
guideline update:
evaluation and man-
agement of concus-
sion in sports: report
of the Guideline
Development Sub-
committee of the
American Academy
of Neurology. Neu-
rology. 2013;
80:2250-7. [PMID:
23508730]
25. Institute of Medi-
cine. Sports-Related
Concussions in
Youth: Improving
the Science and
Changing the Cul-
ture. Washington,
DC: National Acade-
mies Pr; 2013.
26. Master CL, Grady MF.
Office-based man-
agement of pedi-
atric and adolescent
concussion. Pediatr
Ann. 2012;41:1-6.
[PMID: 22953974]
2014 American College of Physicians ITC2-6 In the Clinic Annals of Internal Medicine 4 February 2014
has occurred (2225). The injured
athlete should be removed from
play to allow for adequate assess-
ment and monitoring. This may be
challenging in youth sports because
many do not have trained medical
or athletic training professionals on
the sidelines and most coaches are
volunteer parent coaches. Depend-
ing on the severity of the injury or
the symptoms after an injury and
removal from play, monitoring on
the sideline may be appropriate,
but the athlete should be referred
to the emergency department if
there is any deterioration in clinical
status that causes concern for a
more serious intracranial or cervi-
cal injury. Safe return to play after
a head injury should be overseen
by a medical professional with ex-
perience managing head injury and
concussion. There is currently no
single certification or qualification
needed to perform this assessment,
and the type of medical profession-
al able to undertake this serious re-
sponsibility may vary by geography.
These personnel may include a
primary care physician who has re-
ceived additional training in con-
cussion management; a primary
care sports medicine physician who
has extensive experience dealing
with return-to-play issues after
various sports injuries, including
concussion; or a neurologist, neuro-
surgeon, neuropsychologist, or
physiatrist with experience dealing
with head injury and return-to-
sport issues (2224). To date, 49
states have passed legislation that
mandates clearance of an athlete to
return to play by a licensed medical
professional with experience han-
dling concussions (25).
What items are important in the
history and physical examination
of a patient with suspected
concussion?
The mechanism of injury is impor-
tant to ascertain in the history of
patients with suspected concussion,
as is the timing of the development
of symptoms after injury. The
subsequent course of events should
be determined, including ascertain-
ment of delayed-onset symptoms
and specific activities that may or
may not exacerbate symptoms. A
brief assessment of preinjury func-
tion and ability to tolerate any at-
tempts to return to full function
should also be determined. History
of concussion or such comorbid
conditions as anxiety, depression,
attention deficit hyperactivity
disorder, or preexisting migraine
should also be obtained (20).
During a physical examination, it is
important to conduct a thorough
head, cervical, and neurologic ex-
amination (Table 1). In particular,
the vestibular and oculomotor sys-
tems must be sufficiently perturbed
to identify deficits because these
systems have been found to be af-
fected in concussion (26) and are
not routinely included in a general
examination. A directed assessment
of these systems in the physical ex-
amination of a patient with a sus-
pected concussion is essential. This
includes assessing smooth pursuits,
visual saccades, gaze stability and
vestibulo-ocular reflex (VOR), con-
vergence, and dynamic balance.
A new, brief screening tool to assess
vestibulo-ocular function in persons
with concussion is currently being
validated. The University of
Pittsburgh Medical Center Brief
Vestibular and Ocular Motor
Screening assessment was developed
to assess vestibular and oculomotor
impairment via patient-reported
symptom provocation after each as-
sessment. The Vestibular and Ocular
Motor Screening assessment con-
sists of brief assessments in 5 do-
mains: smooth pursuits, horizontal
and vertical saccades, convergence,
horizontal and vertical VOR, and
visual motion sensitivity. This tool
can be accessed online in the sup-
plement to this article (27).
From a practical standpoint, symp-
toms with provocation of the
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27. Collins MW. In-office
evaluation of sports
concussion: clinical
interview, neurocog-
nitive assessment,
and vestibular-ocu-
lar screening. Pre-
sented at Emerging
Frontiers in Concus-
sion, Pittsburgh,
Pennsylvania, 8 June
2013.
28. Guskiewicz KM, Ross
SE, Marshall SW. Pos-
tural stability and
neuropsychological
deficits after concus-
sion in collegiate
athletes. J Athl Train.
2001;36:263-273.
[PMID: 12937495]
29. Galetta KM, Brandes
LE, Maki K, Dziemi-
anowicz MS, Lau-
dano E, Allen M, et
al. The King-Devick
test and sports-relat-
ed concussion: study
of a rapid visual
screening tool in a
collegiate cohort. J
Neurol Sci.
2011;309:34-9.
[PMID: 21849171]
30. Broglio SP, Puetz TW.
The effect of sport
concussion on neu-
rocognitive function,
self-report symp-
toms and postural
control : a meta-
analysis. Sports Med.
2008;38:53-67.
[PMID: 18081367]
31. Cohen JS, Gioia G,
Atabaki S, Teach SJ.
Sports-related con-
cussions in pedi-
atrics. Curr Opin Pe-
diatr. 2009;21:288-93.
[PMID: 19390439]
2014 American College of Physicians ITC2-7 In the Clinic Annals of Internal Medicine 4 February 2014
vestibulo-oculomotor systems have
implications for activities of daily
life. Difficulties with smooth pur-
suits and saccades are commonly
associated with difficulties at school
and work involving reading or scan-
ning horizontally or vertically, as
occurs when taking notes in a class-
room or working at a computer.
Symptoms with convergence are
often associated with difficulty with
near-visual work, including reading,
as well as the of electronic devices,
such as smartphones and tablets. Pa-
tients with symptoms provoked by
the vertical VOR test often do not
tolerate running or jumping, and
symptoms with the horizontal VOR
test may manifest as motion sickness
in a car or symptoms with any rapid
side-to-side head movement (26).
In addition, balance should be
evaluated in a patient with concus-
sion. The Balance Error Scoring
System is one such standardized
assessment. It produces a compos-
ite score, and certain subtests, such
as single-leg or tandem stance, may
be more specific to concussion
(28). From a physical examination
perspective, we have found that a
dynamic assessment of tandem
heeltoe gait forward and back-
ward with eyes open and closed is
clinically useful and can be fol-
lowed clinically over time. For ease
of direction, tape may be placed on
the floor of the examination space
(hallway rather than examination
room). The Sport Concussion
Assessment Tool 3 (22) has incor-
porated this test and a modified
Balance Error Scoring System as
components of its sideline balance
evaluation. If the patient raises his
arms, steps off the line, or cannot
approximate heeltoe motion,
these findings would be considered
a clinical sign of abnormal balance.
For the oculomotor examination, an
additional test that may be used is
the KingDevick test, which is a
tool that rapidly assesses eye move-
ment and can be used in the office
or on the sideline to determine im-
pairment in eye movements associ-
ated with an acute concussion. This
has been found to be potentially
useful as a tool to determine removal
from play. The 1-minute test in-
volves reading single digits displayed
on cards; any slowing of time to
complete the test, ideally compared
with the athletes baseline, is sugges-
tive of concussion (29).
What other tests should be
performed?
Concussion symptom scales are
helpful in delineating the severity
and extent of symptoms after injury
and can be followed serially. Some
limitations to the utility of these
scales include the possibility of un-
derreporting of symptoms by ath-
letes hoping to return to play or the
overlap of nonspecific symptoms
with other clinical entities. Despite
these limitations, symptom scales
can be helpful in diagnosing con-
cussion, especially in conjunction
with the findings of other deficits
(30), and have been incorporated
into such assessment tools as the
Acute Concussion Evaluation (31)
and Sport Concussion Assessment
Tool 3 (22). Various domains of
brain function should be evaluated
during diagnosis. Use of multiple
tools to accomplish this is helpful
in obtaining a global assessment of
patients with concussion.
Computerized neurocognitive test-
ing, which has been used for many
years at the professional sports level,
has become widely implemented in
recent years in high school and
college sports. It is an important
additional tool to help quantify the
cognitive effects of injury that aids
in the diagnosis and management
of concussion. Data obtained from
neurocognitive testing are helpful
when the appropriate return to a
contact or collision sport is being
considered, and many computerized
neurocognitive tests are commer-
cially available for this use. When
such information is used in the
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32. Meehan WP 3rd,
dHemecourt P,
Collins CL, Taylor AM,
Comstock RD. Com-
puterized neurocog-
nitive testing for the
management of
sport-related con-
cussions. Pediatrics.
2012;129:38-44.
[PMID: 22129538]
33. Sandel NK, Lovell
MR, Kegel NE, Collins
MW, Kontos AP. The
relationship of
symptoms and neu-
rocognitive perform-
ance to perceived
recovery from
sports-related con-
cussion among ado-
lescent athletes.
Appl Neuropsychol
Child. 2013;2:64-9.
[PMID: 23427778]
34. Topolovec-Vranic J,
Pollmann-Mudryj
MA, Ouchterlony D,
Klein D, Spence J,
Romaschin A, et al.
The value of serum
biomarkers in pre-
diction models of
outcome after mild
traumatic brain in-
jury. J Trauma.
2011;71:S478-86.
[PMID: 22072007]
35. Tierney RT, Mansell
JL, Higgins M, McDe-
vitt JK, Toone N,
Gaughan JP, et al.
Apolipoprotein E
genotype and con-
cussion in college
athletes. Clin J Sport
Med. 2010;20:464-8.
[PMID: 21079443]
36. Lau B, Lovell MR,
Collins MW, Pardini J.
Neurocognitive and
symptom predictors
of recovery in high
school athletes. Clin
J Sport Med.
2009;19:216-21.
[PMID: 19423974]
37. Schatz P, Moser RS,
Covassin T, Karpf R.
Early indicators of
enduring symptoms
in high school ath-
letes with multiple
previous concus-
sions. Neurosurgery.
2011;68:1562-7.
[PMID: 21258259]
38. Kontos AP, Elbin RJ,
Lau B, Simensky S,
Freund B, French J,
et al. Posttraumatic
migraine as a predic-
tor of recovery and
cognitive impair-
ment after sport-re-
lated concussion.
Am J Sports Med.
2013;41:1497-504.
[PMID: 23698389]
2014 American College of Physicians ITC2-8 In the Clinic Annals of Internal Medicine 4 February 2014
management of concussion, it is vi-
tal that medical personnel have suf-
ficient experience in interpreting
the results in this context.
Normative data for computerized
neurocognitive testing are available
for patients aged 890 years, de-
pending on the test used. Extensive
data on the reliability, validity,
prognostic ability, and added value
of such testing have been pub-
lished in the past decade. Although
postinjury neurocognitive test
scores can be interpreted without a
baseline for comparison, having
valid and accurate preinjury infor-
mation may contribute to a more
individualized assessment. A com-
puter-based neurocognitive test
also provides additional useful in-
formation when a decision is being
made about an athletes return to
play. In one study, athletes in
whom computer-based neurocog-
nitive testing was used were less
likely to return to play within
10 days of injury (38.5%) than
those in whom it was not used
(55.7%) (32). In addition, these
athletes were more likely to be ap-
proved for return to play by a quali-
fied physician (versus an athletic
trainer or other provider). Such
testing may reduce the risk for pre-
mature return to a contact or colli-
sion sport and subsequent re-injury.
Neurocognitive testing may also be
used to support difficult or contro-
versial return-to-play decisions
when the symptom profile is am-
biguous. Under circumstances in
which athletes are not candid
about the presence of symptoms,
specific patterns of performance
on computerized neurocognitive
testing can detect neurocognitive
deficits with a sensitivity of 94.6%
and a specificity of 97.3% (33).
Thus, they provide some objective
measures on which to base return-
to-play decisions. A limitation of
neurocognitive testing is that re-
sults may be influenced by many
factors aside from concussion. As
such, it is important that a medical
professional with experience man-
aging concussions interpret these
results within the clinical context,
taking into account the entire his-
tory and physical examination as
well as the results of neurocogni-
tive testing. Test results are not in-
tended for use in isolation to
diagnose or manage concussion.
Diagnosis and management are
clinical processes that take into ac-
count all available evidence. When
used in conjunction with the clini-
cal history and physical examina-
tion, neurocognitive testing is a
useful tool to help an experienced
clinician manage concussion.
Finally, there is ongoing research
investigating serum biomarkers
for acute concussion, such as
S100B and neuron-specific eno-
lase (34), and genetic testing for
alleles that may predispose to con-
cussion, such as apolipoprotein E
(35). These tests, however, are
used primarily in the research
realm and currently have limited
clinical application.
How is severity assessed?
Several factors have been suggest-
ed as predictors of prolonged re-
covery after concussion, including
younger age (5, 6), female sex (4),
history of multiple concussions
(8), and diagnosed learning dis-
ability (11). Sub-acute (within
37 days) symptoms, including
fogginess, difficulty concentrat-
ing, vomiting, dizziness, nausea,
headache, slowness, imbalance,
sensitivity to light or sound, and
numbness, seem to predict a re-
covery of 14 days or longer (36).
Other neurocognitive impair-
ments, including slowed reaction
time and impaired visual memory,
have also been shown to be pre-
dictive of prolonged recovery
(37). In addition, posttraumatic
migraine (38) has been associated
with a more severe and protracted
recovery after concussion. Ath-
letes with greater neurocognitive
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39. Lau BC, Collins MW,
Lovell MR. Sensitivity
and specificity of
subacute computer-
ized neurocognitive
testing and symp-
tom evaluation in
predicting outcomes
after sports-related
concussion. Am J
Sports Med.
2011;39:1209-16.
[PMID: 21285444]
40. Lau BC, Collins MW,
Lovell MR. Cutoff
scores in neurocog-
nitive testing and
symptom clusters
that predict pro-
tracted recovery
from concussions in
high school athletes.
Neurosurgery.
2012;70:371-9.
[PMID: 21841522]
2014 American College of Physicians ITC2-9 In the Clinic Annals of Internal Medicine 4 February 2014
impairments on computerized
neurocognitive testing seem to be
94.6% more likely to require 10
or more days to recover (39).
Moreover, specific cutoff values
on certain computerized neu-
rocognitive tests have been shown
to have a high degree of sensitivi-
ty in predicting symptoms lasting
a month or longer (40).
A retrospective cohort study published in
2011 identified statistically significant
cutoff scores distinguishing short and
protracted recovery groups. Using receiv-
er-operating characteristic curve analy-
sis, migraine symptom cluster (headache,
visual problems, dizziness, noise or light
sensitivity, nausea or vomiting, balance
problems, and numbness or tingling) (to-
tal of 18), cognitive symptom cluster
(fatigue fogginess, drowsiness, difficulty
concentrating or remembering, or cogni-
tive slowing) (total of 19), ImPACT visual
memory (46), and ImPACT processing
speed composite scores (23.5) distin-
guish between short and prolonged
recovery with 80% sensitivity. The individ-
ual positive predictive value of each
cutoff score is low (41.3%47.1%) but im-
proves when the scores are used together
(positive predictive value, 73.17%). The
mean recovery time was 7 days in the
short recovery group and 33 days
in the protracted recovery group (40).
Grading systems for concussion have
been abandoned, and in general, the
severity of concussion can only truly
be assessed after the course of recov-
ery is complete because of the lack of
data with which to predict the prog-
nosis of concussion.
The rest period varies for each indi-
vidual; it may be a few days for
adults, and in some cases, somewhat
longer for children and adolescents.
Immediately after injury, avoiding
activities that exacerbate concussion
symptoms seems to help those symp-
toms to abate. For athletes, it is im-
portant to rest from provocative
physical activity that worsens symp-
toms in the acute early postinjury
phase. It is also essential that they re-
frain from participating in any con-
tact or collision activities that present
risk for repeated head injury during
this vulnerable acute postinjury
phase. After a brief period of physical
Should patients with concussion
be restricted from work, school, or
other activities?
Patients with concussion seem to
benefit from a brief period of phys-
ical and cognitive rest immediately
after the injury in order to help
symptoms decrease (41, 42).
In a retrospective cohort study of high
school athletes, those with the highest lev-
els of physical and cognitive activity had
worse postconcussion symptom scores
and neurocognitive performance on test-
ing, particularly in the areas of visual
memory (P = 0.003) and reaction time
(P < 0.001), compared with those with in-
termediate or lower levels of activity (42).
Diagnosis... Historically, concussion has been defined as a constellation of subjec-
tive symptoms after head injury without any objective radiologic or physical ex-
amination findings. Recent work in concussion evaluation has identified specific
areas that are commonly affected in concussion that can be identified on physical
examination. These systems must be targeted in the physical examination when
concussion is suspected. Concussion is a clinical diagnosis, and it is essential to
obtain a detailed and accurate history and to assess the neurocognitive, vestibu-
lar, oculomotor, and balance systems during physical examination to identify
deficits establishing the diagnosis.
CLINICAL BOTTOM LINE
Treatment
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41. Moser RS, Glatts C,
Schatz P. Efficacy of
immediate and de-
layed cognitive and
physical rest for
treatment of sports-
related concussion.
J Pediatr. 2012;
161:922-6. [PMID:
22622050]
42. Majerske CW, Miha-
lik JP, Ren D, Collins
MW, Reddy CC,
Lovell MR, et al. Con-
cussion in sports:
postconcussive ac-
tivity levels, symp-
toms, and neurocog-
nitive performance.
J Athl Train.
2008;43:265-74.
[PMID: 18523563]
43. Grady MF, Master CL,
Gioia GA. Concus-
sion pathophysiolo-
gy: rationale for
physical and cogni-
tive rest. Pediatr Ann.
2012;41:377-82.
[PMID: 22953984]
44. Master CL, Gioia GA,
Leddy JJ, Grady MF.
Importance of re-
turn-to-learn in pe-
diatric and adoles-
cent concussion.
Pediatr Ann.
2012;41:1-6.
[PMID: 22953975]
45. Halstead ME,
McAvoy K, Devore
CD, Carl R, Lee M, Lo-
gan K; Council on
Sports Medicine and
Fitness. Returning to
learning following a
concussion. Pedi-
atrics. 2013;132:948-
57. [PMID: 24163302]
2014 American College of Physicians ITC2-10 In the Clinic Annals of Internal Medicine 4 February 2014
and cognitive rest, during which
symptoms subside, patients may re-
sume cognitive and physical activities
gradually while taking care not to
undertake activities that result in
severe symptom exacerbation (20,
4146). This period of gradual return
to normal cognitive activity, whether
at work or school, may require signif-
icant modifications because the
injured patient will be unable to im-
mediately resume full normal activi-
ties after the injury and rest period.
These modifications may include re-
duced workload, shortened school or
workdays, and frequent breaks to al-
low provokable symptoms to resolve.
Simultaneously, patients may begin a
gradual return to physical activity as
tolerated, again while paying close at-
tention to symptom threshold. Ath-
letes should generally be restricted
from formal athletic training until
they are able to tolerate a full cogni-
tive load, such as a full day of school.
When ready, the athlete may enter a
formal return-to-play progression
(20), gradually increasing physical ac-
tivity back to training levels, avoiding
severe symptom exacerbation, and
advancing in a stepwise progression
that eventually includes a supervised
return to contact activities. For those
with prolonged concussion symp-
toms, there is increasing evidence
that noncontact aerobic activity is not
harmful and may, in fact, be helpful
in recovery from concussion (46).
What behavioral interventions are
helpful?
Specific written instructions and
guidelines for patients and families
about physical and cognitive rest are
helpful, along with guidance for
monitoring symptoms during the
brief period of physical and cogni-
tive rest to promote symptom allevi-
ation (47). Physical rest refers to a
level of activity that keeps symptoms
at a minimum and may be below
the level of normal daily activity for
the individual. There is pathophysi-
ologic evidence of a metabolic mis-
match in concussion that occurs
after the injury. The injured brain
has an increased metabolic demand
that exceeds the temporarily uncou-
pled cerebral blood flow response as
a result of the injury (48). We have
found that, until the patient is suffi-
ciently recovered, provocative activi-
ties that trigger severe symptom
exacerbation should be avoided. In
addition, during the acute rest peri-
od, patients may find that they have
an increased need for sleep. We en-
courage patients to get adequate
amounts of sleep while maintaining
a regular sleepwake cycle during
the recovery process.
Specific instructions for cognitive rest
are helpful to patients. Besides disen-
gaging briefly from work or school,
the rest period should include tempo-
rary avoidance of electronic devices,
such as computers, video games, and
cellphones for text messaging, be-
cause these activities seem to cause
significant symptom exacerbation.
Once symptoms have improved, a
gradual reintroduction of cognitive
activities may be initiated, taking care
not to trigger severe symptoms by
taking breaks when symptoms devel-
op. This seems to help patients build
cognitive stamina over time. For stu-
dents, a trial of cognitive activity at
home, such as school-related work,
seems to be beneficial in determining
their stamina for a return to partial-
or full-day school (44, 45). For adults
returning to work, a similar strategy
of attempting self-paced cognitive
work at home with breaks before re-
turning to partial- or full-day work
also seems to be helpful. Thereafter, a
gradual increase in workload and
time at work and school may be un-
dertaken, with modifications as need-
ed (see the Box: Return to Activity).
For athletes, formal return-to-play
protocols have been published with
the aim of guiding a graded in-
crease in physical training and dy-
namic activity (20). In children and
adolescents, we delay initiation of a
return-to-play protocol for sport-
specific training purposes until the
student-athlete has demonstrated
Downloaded From: http://annals.org/ by Norbertus Robben on 05/15/2014
46. Baker JG, Freitas MS,
Leddy JJ, Kozlowski
KF, Willer BS. Return
to full functioning
after graded exercise
assessment and pro-
gressive exercise
treatment of post-
concussion syn-
drome. Rehabil
Res Pract.
2012;2012:705309.
[PMID: 22292122]
47. Arbogast KB, McGin-
ley AD, Master CL,
Grady MF, Robinson
RL, Zonfrillo MR.
Cognitive rest and
school-based rec-
ommendations fol-
lowing pediatric
concussion: the
need for primary
care support tools.
Clin Pediatr (Phila).
2013;52:397-402.
[PMID: 23447397]
48. Giza CC, Hovda DA.
The neurometabolic
cascade of concus-
sion. J Athl Train.
2001;36:228-235.
[PMID: 12937489]
49. Meehan WP 3rd.
Medical therapies for
concussion. Clin
Sports Med.
2011;30:115-24, ix.
[PMID: 21074086]
50. Reddy CC, Collins M,
Lovell M, Kontos AP.
Efficacy of amanta-
dine treatment on
symptoms and
neurocognitive per-
formance among
adolescents follow-
ing sports-related
concussion. J Head
Trauma Rehabil.
2013;28:260-5.
[PMID: 22613947]
2014 American College of Physicians ITC2-11 In the Clinic Annals of Internal Medicine 4 February 2014
the ability to tolerate a full return
to cognitive activities and workload
at school (generally meaning a full
day of school and full workload, in-
cluding testing, without symp-
toms). This, however, does not
mean that they are sedentary dur-
ing this period of return to learn.
On the contrary, noncontact aero-
bic activity may have a significant
benefit for all patients after the rest
period (46) and may be advanced as
symptoms permit. Student-athletes
may gradually reintroduce light or
brisk walking or other aerobic ac-
tivity as tolerated while returning
to full cognitive activity. Only the
formal return-to-play protocol,
which implies a more strenuous
level of aerobic and strength train-
ing in preparation for a return to
competitive sport, is delayed until
after the full resumption of cogni-
tive workload without symptoms
(24, 43).
Are any pharmacologic measures
known to be helpful?
Pharmacologic interventions in
concussion have had limited suc-
cess in mitigating symptoms. Suc-
cessful return to full cognitive and
physical activities generally can be
accomplished without medication.
In the immediate postinjury acute
phase, analgesics, such as aceta-
minophen, ibuprofen, and naprox-
en (49), may be helpful, but we
have found that symptoms seem to
be managed best with behavioral
interventions, such as relative
physical and cognitive rest and
modification of activities. Daily
use of analgesics should be avoided
to prevent development of re-
bound headaches. For patients
with disordered sleep, which is
common after concussion, mela-
tonin is a safe option for use in the
adult and pediatric populations.
Prescription sleep aids are some-
times used in adults, but limited
evidence supports their use. For
patients who describe significant
mental slowing or fogginess, pre-
liminary evidence suggests that
amantadine may be helpful during
the recovery phase of concussion
(50). For patients who develop
chronic daily headaches outside of
the acute phase of concussion,
medication options include
amitriptyline and topiramate. The
former can have adverse cardiac
effects that must be recognized but
also has the side effect of sedation,
which may be helpful in persons
with disrupted sleep, and a mild
antidepressant effect for those in
whom mood is an issue. With
Return to Activity
Return to school/work
Cognitive restNo school/work,
homework, texting, video games,
computer work
Relative restReintroduce short periods
(515 minutes) of aforementioned
activities that do not trigger severe
symptom exacerbation
Homework/work at homeLonger
periods of cognitive activity (2030
minutes) to build stamina, avoiding
triggering severe symptoms
Return to school/workPartial-day
school/work with accommodations
after tolerating 12 cumulative hours
of homework at home
Ramp up to full dayWith
accommodations for full work load,
limited make up work
Full return to school.workFull day, full
work load, fully caught up with make-
up load
Return to play
Physical restEncourage healthy sleep,
additional sleep may be needed, no
activities that result in sustained
increased heart rate or breaking a
sweat or severe symptom exacerbation
Light activity associated with everyday
life avoiding triggering severe
symptomswalking
Light aerobic exerciseBrisk walking,
light jogging to increase heart rate
without triggering severe symptom
exacerbation
Sport-specific aerobic exercise
Noncontact skating, dribbling, or
running drills as tolerated
Advance to complex noncontact sport-
specific training drills and add
resistance training as tolerated
After medical clearance, full contact
practice
Normal game play
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51. Whyte J, Hart T,
Schuster K, Fleming
M, Polansky M,
Coslett HB. Effects of
methylphenidate on
attentional function
after traumatic brain
injury. A random-
ized, placebo-
controlled trial. Am J
Phys Med Rehabil.
1997;76:440-50.
[PMID: 9431261]
52. Williams SE, Ris MD,
Ayyangar R, Schefft
BK, Berch D. Recov-
ery in pediatric brain
injury: is psychos-
timulant medication
beneficial? J Head
Trauma Rehabil.
1998;13:73-81.
[PMID: 9582180]
53. Aligene K, Lin E.
Vestibular and bal-
ance treatment of
the concussed ath-
lete. NeuroRehabili-
tation. 2013;32:543-
53. [PMID: 23648608]
54. Cap-Aponte JE,
Urosevich TG,
Temme LA, Tarbett
AK, Sanghera NK. Vi-
sual dysfunctions
and symptoms dur-
ing the subacute
stage of blast-in-
duced mild traumat-
ic brain injury. Mil
Med. 2012;177:804-
13. [PMID: 22808887]
55. Vidal PG, Goodman
AM, Colin A, Leddy
JJ, Grady MF. Reha-
bilitation strategies
for prolonged recov-
ery in pediatric and
adolescent concus-
sion. Pediatr Ann.
2012;41:1-7.
[PMID: 22953976]
2014 American College of Physicians ITC2-12 In the Clinic Annals of Internal Medicine 4 February 2014
regard to topiramate, clinicians
should be aware that cognitive
slowing may be a significant ad-
verse effect. Methylphenidate has
been successfully used to treat per-
sistent attention issues after trau-
matic brain injury in adults (51),
but studies in children are con-
flicting (52). In the prolonged
chronic postconcussion phase, re-
ferral for adjunctive counseling
and psychotropic medication for
anxiety and depression may be
warranted (49).
What are the complications?
Complications vary. The deficits
that most often persist beyond the
acute phase include vestibular
deficits (53) and oculomotor and
visual convergence deficits (54).
Anxiety and depression may also
persist after the acute phase, as well
as chronic headaches and attention
or concentration issues in students.
Cognitive issues that may affect
school and work performance, such
as slowed processing speed or
memory issues, may also persist.
Postconcussion syndrome is a
term reserved for symptoms that
are prolonged and persistent and
may involve multiple domains of
brain function.
When should rehabilitation
therapies be considered?
Rehabilitation with occupational
or physical therapy, specifically
vestibular therapy (53, 55), should
be considered if vestibulo-ocular
deficits persist beyond the acute
phase. In these cases, directed
vestibular therapy seems to signifi-
cantly reduce symptoms and im-
prove function. Vestibular therapy
should include targeted rehabilita-
tion of balance and oculomotor
function, including exercises for
saccades, VOR or gaze stability,
and convergence, using a Brock
string or other such tool. At this
stage, aerobic rehabilitation with
exercise training also plays a bene-
ficial role in rehabilitation from
concussion (47). Formal binocular
vision therapy may also be indicat-
ed for patients with more signifi-
cant visual issues that persist in
the postconcussion phase (54, 56).
Cognitive or speech therapy may
be indicated for patients who have
persistent executive functioning
and memory deficits, especially in
those who have not been able to
resume their preinjury level of
function (57). For children, school
seems to be therapeutic such that
modification and support of
school activities may be sufficient
to rehabilitate cognitive deficits
from concussion. If more signifi-
cant accommodations need to be
made involving a 504 Plan or an
individualized education plan,
referral for cognitive or speech
therapy after comprehensive neu-
ropsychological evaluation may be
useful (23).
When should a specialist be
consulted for treatment of
concussion?
Primary care physicians who are
trained in the management of con-
cussions with a straightforward re-
covery trajectory do not need to
consult a specialist if they feel com-
fortable guiding a patient through
the period of rest and gradual re-
turn to full activity. If there is con-
cern about the timing of return to a
contact or collision sport, referral to
a primary care sports medicine
physician, neurosurgeon, neuropsy-
chologist, physiatrist, or sports neu-
rologist with experience in sports
concussion may be helpful in deter-
mining appropriate timing for re-
turn to contact or collision play. If
there are concerns about a patient
with a prolonged recovery from
concussion where rehabilitation
may be required, referral to a spe-
cialist with concussion expertise to
oversee care may be helpful. Pa-
tients with multiple concussions or
preexisting neurologic issues, such
as migraines, anxiety, or depression,
may also benefit from early referral
to the appropriate specialist.
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56. Lavrich JB. Conver-
gence insufficiency
and its current treat-
ment. Curr Opin
Ophthalmol.
2010;21:356-60.
[PMID: 20634696]
57. Tsaousides T, Gor-
don WA. Cognitive
rehabilitation follow-
ing traumatic brain
injury: assessment to
treatment. Mt Sinai J
Med. 2009;76:173-
81. [PMID: 19306374]
58. Makdissi M, Davis G,
Jordan B, Patricios J,
Purcell L, Putukian
M. Revisiting the
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should the evalua-
tion and manage-
ment of acute con-
cussions differ in
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2013;47:314-20.
[PMID: 23479491]
59. McCrea M,
Guskiewicz K, Ran-
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Hammeke TA, Mar-
shall SW, et al. Inci-
dence, clinical
course, and predic-
tors of prolonged
recovery time fol-
lowing sport-related
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athletes. J Int Neu-
ropsychol Soc.
2013;19:22-33.
[PMID: 23058235]
2014 American College of Physicians ITC2-13 In the Clinic Annals of Internal Medicine 4 February 2014
What factors predict prognosis?
A greater number and severity of
symptoms after concussion has been
shown to predict a poorer prognosis
and prolonged recovery from concus-
sion. Specific symptoms that have
been reported to be associated with
prolonged recovery include amnesia,
prolonged headache, fatigue or foggi-
ness, cognitive problems, and dizzi-
ness at the time of injury (40, 58).
Loss of consciousness and impact
seizure have not been shown to con-
sistently correlate with poorer out-
come, but these symptoms still war-
rant clinical vigilance and there may
be negative prognostic implications,
especially if loss of consciousness is
prolonged (>1 minute) (58).
A history of concussion, especially
multiple concussions, is a well-
established negative prognostic factor
for concussion outcome (8). Studies
have found younger age to be associ-
ated with prolonged recovery, neces-
sitating a more conservative approach
to treating children and adolescents
with concussion (6). Sex differences
in the rates of concussion have also
been reported in comparison of
sports with similar rules for males
and females (for example, soccer and
basketball) (4).
From a genetic perspective, emerging
evidence suggests that apolipopro-
tein e4 genotype may be associated
with more significant neurologic
deficits later in life after multiple
concussive and subconcussive injuries
(35), but such testing is currently
limited to the research realm.
What should patients and families
be told about the likely course of
recovery?
In most cases, a straightforward re-
covery from an acute concussion may
range from a few days to 12 weeks
(59). Beyond that, if symptoms per-
sist, vestibular therapy (53, 55), aero-
bic rehabilitation (46), and binocular
vision therapy (54, 56), among other
strategies, may be used to return the
patient to an improved level of func-
tion. We have found that patients
with prolonged recovery may take
from 1 to many months for recovery.
Treatment... Many concussions with a straightforward recovery trajectory may be
managed by primary care physicians who feel comfortable with the management
of acute concussion. A brief period of early physical and cognitive rest after the
injury followed by a period of gradual reentry into physical and cognitive activi-
ties with activity modification to minimize symptom exacerbation is often suffi-
cient for most patients with a typical recovery. Patients with preexisting comorbid
conditions or risk factors or prolonged symptoms after the concussion may bene-
fit from referral to a specialist with experience in managing concussion to facili-
tate rehabilitation and a full return to work, school, activity, or sport.
CLINICAL BOTTOM LINE
Prognosis
Prognosis... Many patients with concussion will recover with few, if any, long-term se-
quelae. However, there are known risk factors that may predict a prolonged recovery,
namely the number and severity of postconcussion symptoms and a history of concus-
sion. Any deficits that persist despite rehabilitation, such as cognitive or mental health
issues, must be taken into consideration after an acute concussion with regard to fu-
ture activities. It is vital that physicians engage patients and their families in a discus-
sion weighing the future risk for concussion with the benefits of participating in a
high-risk activity to make a medically informed decision.
CLINICAL BOTTOM LINE
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I
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t
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l
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n
i
c
Tool Kit
In the Clinic
Concussion
ACP Smart Medicine Module
http://smartmedicine.acponline.org/content.aspx?gbosId=484
http://smartmedicine.acponline.org/content.aspx?gbosId=100
http://smartmedicine.acponline.org/content.aspx?gbosId=441
http://smartmedicine.acponline.org/content.aspx?gbosId=176
Access the ACP Smart Medicine modules on falls, stroke and
transient ischemic attack, preparticipation in sports physical, and
posttraumatic stress disorder from the American College of
Physicians. ACP Smart Medicine modules provide evidence-
based, updated information on current diagnosis and treatment in
an electronic format designed for rapid access at the point of care.
Patient Information
http://smartmedicine.acponline.org
Patient information for duplication and distribution to patients.
www.nlm.nih.gov/medlineplus/concussion.html
www.nlm.nih.gov/medlineplus/tutorials/traumaticbraininjury/htm/
index.htm
www.nlm.nih.gov/medlineplus/spanish/tutorials/traumaticbrain
injuryspanish/htm/index.htm
Resources related to concussion from the National Institutes of
Healths MedlinePlus, including a tutorial on traumatic brain
injury in English and Spanish.
www.cdc.gov/concussion/
www.cdc.gov/concussion/get_help.html
Information from the Centers for Disease Control and
Prevention (CDC) on concussion, including a patient brochure
on concussion and where to get help.
Clinical Guidelines
www.healthquality.va.gov/mtbi/concussion_mtbi_full_1_0.pdf
Practice guideline from the Department of Veterans Affairs and
Department of Defense for the management of concussion/mild
traumatic brain injury, released in 2009.
Diagnostic Tests and Criteria
www.kingdevicktest.com/for-concussions/
www.pdhealth.mil/downloads/MACE.pdf
Commonly used tests for evaluating concussion include the short
KingDevick test and the longer, more detailed Military Acute
Concussion Evaluation.
www.knowconcussion.org/concussion-management/graded-symptom
-scale-checklist/
The Graded Symptom Checklist is a short patient questionnaire
to measure the severity of symptoms after a head injury.
www.ncbi.nlm.nih.gov/pubmed/9575254
The Standardized Assessment of Concussion is a brief screening
test for neurologic and cognitive function.
www.bidmc.org/CentersandDepartments/Departments/Neurology/
ConcussionandTraumaticBrainInjuryClinic/EducationalInformation
AboutTraumaticBrainInjury/GlasgowComaScale.aspx
The Glasgow Coma Scale is a 15-point test for assessing the
initial severity of a brain injury.
www.nlm.nih.gov/medlineplus/ency/article/003786.htm
www.nlm.nih.gov/medlineplus/ency/article/003802.htm
Information on cranial computed tomography scan and skull
radiography, two imaging tests that may be used for concussion
assessment.
Quality of Care Guidelines
http://clinicaltrials.gov/search/open/condition=%22Brain+Concussion
%22
http://clinicaltrials.gov/search/open/condition=%22Brain+Injuries%22
http://clinicaltrials.gov/search/open/condition=%22Craniocerebral
+Trauma%22
Information on clinical trials on brain concussion, brain injury,
and craniocerebral trauma.
4 February 2014 Annals of Internal Medicine In the Clinic ITC2-14 2014 American College of Physicians
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In the Clinic
Annals of Internal Medicine
P
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f
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a
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THINGS YOU SHOULD
KNOW ABOUT
CONCUSSION
What is concussion?
A serious injury that damages the brain
Also referred to as mild traumatic brain injury
Results from a jolt, collision, or bump to the head
Causes include:
motor vehicle or bicycle accidents
falls
sports participation
combat-related blasts
What are the signs and symptoms?
Headache, dizziness, balance problems, or blurry vision
Nausea or vomiting
Confusion
Memory or concentration problems
Light or noise sensitivity
Emotional changes
Impaired sleep
How is it diagnosed?
Your doctor will ask questions about your injury and
symptoms and conduct a physical examination.
Screening tests may be used to assess your symptoms
and their severity.
Imaging tests, such as cranial computed tomography
(CT) scan, may be needed to assess your injury.
How is it treated?
Rest to help the brain heal.
Avoid activities that could lead to another concussion.
Avoid alcohol and other drugs that could slow recovery.
Recovery is usually quick and complete, but in some
cases the effects persist.
The severity of the concussion and patient age and
health before the concussion may affect recovery.
If symptoms return or new symptoms develop, take
more time for rest and recovery.
Seek emergency treatment if symptoms worsen.
For More Information
www.chop.edu/concussion
Education, support, and other resources on concussion for student
athletes, their families, coaches, teachers, and school personnel
from the Children's Hospital of Philadelphia
www.cdc.gov/traumaticbraininjury/prevention.html
Information from the Centers for Disease Control and Prevention
(CDC) on preventing concussion.
www.cdc.gov/concussion/what_to_do.html
Information from the CDC on what to do if a concussion occurs.
www.cdc.gov/concussion/feel_better.html
Information from the CDC on recovering from a concussion.
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CME Questions
4 February 2014 Annals of Internal Medicine In the Clinic ITC2-16 2014 American College of Physicians
Questions are largely from the ACPs Medical Knowledge Self-Assessment Program (MKSAP, accessed at
http://www.acponline.org/products_services/mksap/15/?pr31). Go to www.annals.org/intheclinic/
to complete the quiz and earn up to 1.5 CME credits, or to purchase the complete MKSAP program.
1. A 15-year-old football player has a high-
impact helmet-to-helmet collision on the
field, develops a headache, and comes
out of the game. He has no loss of
consciousness, nausea, or vomiting. He
has no scalp hematoma and has no neck
pain. He is a little dizzy but is otherwise
acting normally according to his parents.
They decide to bring him to the
emergency department to be evaluated.
On physical examination, he has
difficulty with smooth pursuits and his
balance is affected.
Which of the following approaches
would be appropriate in managing this
patient?
A. Magnetic resonance imaging (MRI) of
the brain
B. MRI of the brain with contrast
C. Observation for 46 hours after the
injury
D. Computed tomography with contrast
E. Cervical spine x-rays
2. A 13-year-old gymnast lands on her
buttocks and arms after a dismount from
the vault at practice. She does not hit
her head directly on the ground. She
finishes her practice and begins to have
headache and dizziness that evening. She
has trouble falling asleep and has
multiple awakenings through the night.
She goes to school with a headache,
which becomes much worse by the end
of the first period. The noise from the
school bus and the lights at school are
making her headache worse, and now
she also feels dizzy and has nausea
without vomiting. The school nurse calls
her mother to pick her up, and she is
brought to the office to be evaluated.
Which physical examination deficits
might be found in this patient?
A. Memory deficits
B. Balance deficits
C. Symptoms with oculomotor
examination
D. Convergence insufficiency
E. All of the above
3. A 22-year-old college soccer player
sustained a concussion during his last
season of play 3 months ago. He
continues to have trouble with dizziness
and nausea as well as motion sickness in
the car. He has eye fatigue and frontal
headaches with prolonged reading as
well as blurry vision with near visual
work. He is managing his school work,
but his performance has declined and he
has difficulty concentrating. He has not
returned to any form of physical activity.
Which rehabilitative approaches may be
helpful at this stage?
A. Vestibular therapy
B. Binocular vision therapy
C. Aerobic conditioning and rehabilitation
D. Neuropsychology testing
E. All of the above
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